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Release of Employee Medical Records <br />Attachment 6-1 <br />Sample Authorization letter for the release of employee medical record information to a designated <br />representative <br />1, , (full name of worker/patient) hereby authorize <br />(individual or organization holding the medical records) to release to <br />(individual or organization authorized to receive the medical information), the following medical information <br />from my personal medical records: <br />(Describe below: In general words, the information desired to be released). <br />I give my permission for this medical information to be used for the following purpose: <br />But I do not give permission for any other use or re -disclosure of this information. <br />(Note: Several extra lines are provided below so that you can place additional restrictions on this <br />authorization letter if you want to. You may, however, leave these lines blank. On the other <br />hand, you may want to (1) specify a particular expiration date for this letter (if less than one year); (2) <br />describe medical information to be created in the future that you intend to be covered by this authorization <br />letter; or (3) describe portions of the medical information in your records which you do not intend to be <br />released as a result of this letter.) <br />Full (printed) name of Employee or Legal Representative: <br />Signature of Employee or Legal Representative & Date: <br />15 <br />